Healthcare Provider Details

I. General information

NPI: 1124202072
Provider Name (Legal Business Name): ANTHONY PENNIE LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 PENHURST ST
ROCHESTER NY
14619-1518
US

IV. Provider business mailing address

52 PENHURST ST
ROCHESTER NY
14619-1518
US

V. Phone/Fax

Practice location:
  • Phone: 585-647-1882
  • Fax: 585-271-7948
Mailing address:
  • Phone: 585-647-1882
  • Fax: 585-271-7948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number286751-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: